Why I Perform a Deep Plane Facelift: A Surgeon’s Perspective

What Actually Happens When I Enter the Deep Plane?

During a deep plane facelift, I begin by elevating the skin to the point where I want to enter the deeper layer. I then enter beneath the SMAS and continue the dissection in that deeper plane.

This is where anatomy becomes extremely important.

Once I am underneath the SMAS, I am working in an area where I need to understand the relationship between the retaining ligaments, the parotid gland, the facial muscles and the branches of the facial nerve.

The goal is not to go deep simply for the sake of going deep. I am entering that plane because it gives me access to structures that may need to be released before I can reposition the descended facial tissues.

Going underneath the SMAS is an access point. What I accomplish after I get there is what matters.

Why Retaining Ligament Release Matters to Me

I often explain retaining ligaments to patients using a tug-of-war analogy. Imagine that I am trying to move your facial tissues in one direction, but the retaining ligaments are the team on the other end of the rope pulling against me. I can keep pulling harder, but those attachments are still creating resistance.

If the anatomy I am trying to correct requires those tissues to move, releasing the appropriate retaining ligaments removes that opposing tension. Now I can reposition the deeper tissues rather than simply trying to overcome the resistance from structures that are still holding them down.

That is one of the major reasons I use a deep plane approach in the right patient.

What This Looks Like in a Real Patient

Debra is a good example of how this anatomy-first approach works in a real patient.She was 58 when she came to see me. The first area that had really started bothering her was her neck. As time went on, she also began noticing changes throughout the rest of her face. But when we talked about what she most wanted me to improve, the neck was her home run.

I still wasn’t going to look only at her neck. I evaluated the entire face and neck because the surgery has to account for how those areas relate to one another.

Debra had substantial neck laxity and required significant work in the neck. She also had changes elsewhere in the face that we wanted to address. Her final plan included a deep plane facelift and deep neck lift along with a brow lift, upper eyelid surgery, facial fat transfer, upper and lower lip lift and a chemical peel.

I think it is important to tell you that before showing you her result. This was comprehensive facial rejuvenation. I don’t want you looking at Debra and assuming every change you see came from a deep plane facelift alone.

What her case demonstrates is the decision-making behind the surgery. I identified the anatomy that needed to be corrected, determined how much work those areas required and built the surgical plan around her.

Why Don’t All Surgeons Perform Deep Plane Facelifts?

The deep plane facelift is not a new surgery. Surgeons have been developing and refining these concepts for decades. What has continued to improve is our understanding of facial anatomy and how to work safely within these deeper layers.

When you work beneath the SMAS, there is important anatomy nearby. The facial nerve is there. The parotid gland is there. The muscles responsible for facial movement are there.

That means a surgeon has to be extremely comfortable with this anatomy.

My background is in head and neck surgery, so this is an anatomical region I have spent a tremendous amount of my career studying and operating in. That training influences the way I think about facial rejuvenation and the way I approach deeper facial dissection.

The question isn’t whether every surgeon should perform the same facelift. The question is whether the surgeon understands the anatomy, understands the surgery being performed and can choose an approach appropriate for the individual patient.

Deep Plane Is More Than Going Beneath the SMAS

This is an important distinction because procedure names can become confusing very quickly.

A surgeon can enter beneath the SMAS for a short distance. That technically describes a deeper dissection, but it does not tell you how far that dissection went, which retaining ligaments were released or how much mobility was created in the facial tissues.

When I am performing a full deep plane release, I am evaluating whether I have actually released the structures that were restricting the movement I wanted to achieve.

One of the ways I assess that intraoperatively is very simple. If the release I am trying to accomplish is complete, I should be able to move through that plane without continuing to encounter the same ligamentous resistance.

The procedure name alone does not tell me what was actually done underneath the skin.

What I Learned From a Revision Facelift

I had a revision patient who had previously been told that she had undergone a deep plane facelift. When I went back into the face during her revision, I could see evidence of the previous surgery in the more superficial tissues. There was scar tissue where I would expect to see it after prior dissection.

But when I evaluated the deeper plane, I did not see the evidence I would expect if that deeper dissection and release had actually been performed.

That case reinforced something I think is increasingly important for patients to understand: the name attached to a surgery does not necessarily tell you the details of what happened during surgery.

I care much more about the anatomy that was addressed, which structures were released and where the tissues were repositioned than I do about putting a fashionable name on the procedure.

Why Skin Tension Matters to Me

One of my goals during facelift surgery is to avoid asking the skin to do work that I believe should be accomplished by deeper tissues.

When the retaining structures have been released appropriately and I can reposition the deeper tissues, the skin can lie back over that new foundation with less tension. Then I can evaluate the excess skin and trim what is appropriate rather than relying on the skin itself to create the lift.

That does not mean every facelift performed with a different technique is a skin-only facelift and it does not mean another technique automatically creates excessive tension. There are multiple established ways to perform facial rejuvenation successfully.

It means that when I choose a deep plane surgery, one of the things I value is the ability to create mobility and repositioning beneath the skin.

I want the deeper facial tissues providing the repositioning. I don’t want the skin closure carrying unnecessary tension.

Does Deep Plane Mean More Natural or Longer Lasting?

I use deep plane techniques because I like what the access and ligament release allow me to accomplish in appropriately selected patients. I can reposition descended tissues, address the cheek and jawline and reduce how much I am relying on skin tension.

Those are surgical reasons I value the technique.

But I think we have to be careful when those principles get turned into absolute claims that every deep plane facelift will look more natural or last longer than every other facelift.

Facelift results depend on more than the name of the technique. They depend on the patient’s anatomy, skin quality, degree and location of aging, the extent of the surgery, the surgeon’s execution and what is being compared.

That is why I separate my surgical preference from what the comparative evidence can actually prove.

What I Want a Facelift to Look Like One Year Later

Mary gives me a different way to show you what I mean. This is not another recovery story. I am showing you Mary because this conversation took place one year after her surgery, when the early swelling and facelift recovery were well behind her and she was simply living with her result.

Mary was 56 at this visit. Her facial rejuvenation included my 4D Facelift™, deep neck lift, facial fat transfer, stem cell nanofat treatment and upper and lower eyelid surgery.

At one year, she told me she felt refreshed and more comfortable being in photographs. But one of the things that stood out to me most was what other people were not noticing. A coworker actually questioned whether she had undergone a facelift until Mary showed her the before photographs.

That matters to me. I want to see improvement in the jawline, neck and facial contours, but I still want the person looking back at you to be recognizable as you.

Patients sometimes see a result like Mary’s and ask me for “the Mary.” But there is no Mary facelift. Her surgery was designed around her anatomy. Another patient can walk into my office asking for the same result and need a very different surgical plan.

The goal is not to reproduce another patient’s facelift. It is to understand your anatomy well enough to create the right facelift for you.

Mary’s result is also a good reminder of why I don’t start a consultation by deciding which named facelift I am going to perform. Her surgery belonged to her. The next patient’s surgery has to belong to that patient.

Deep plane is one of the tools I can use to create that plan. It is not the plan itself.

PATIENT SELECTION

Why I Don’t Perform a Full Deep Plane Facelift on Everyone

If deep plane surgery gives me this degree of access and release, you might reasonably ask why I don’t just perform a full deep plane facelift on every patient.

Because not every patient has the same problem.

If I examine you and most of your aging is concentrated around the neck with slight jawline change and very little midface descent, I may not need a comprehensive deep plane surgery. That is the type of anatomy where my RT Mini Facelift may make more sense.

If your primary problem is midface descent, you have good skin quality and elasticity, and you are genuinely happy with your neck, an endoscopic vertical-vector deep plane midface lift may allow me to address the area that has changed without performing a traditional incision in front of the ear.

If you have more significant changes involving the midface, jawline, loose skin and neck, then a comprehensive face and neck lift may be the appropriate surgery.

These are not different levels on a menu where the biggest surgery is automatically the best surgery.

They solve different anatomical problems.

The question isn’t, “Can I perform a deep plane facelift?” The question is, “Does your face need one?”

So Why Do I Perform Deep Plane Facelifts?

I perform deep plane facelifts because there are patients whose anatomy benefits from that degree of release and repositioning. I value the ability to work beneath the SMAS, release retaining ligaments when necessary and reposition deeper facial tissues without asking the skin to provide the entire lifting force.

But deep plane is not my starting point.

Your anatomy is.

I may examine you and recommend a full deep plane face and neck lift. I may recommend an RT Mini Facelift. I may recommend an endoscopic vertical-vector deep plane midface lift. There are also patients I will tell that they are not ready for facelift surgery at all.

The procedure comes after the diagnosis.